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Low-value clinical practices in injury care

A scoping review and expert consultation survey

Moore, Lynne PhD; Lauzier, François MD, MSc; Tardif, Pier-Alexandre MA, MSc; Boukar, Khadidja Malloum MSc; Farhat, Imen MSc; Archambault, Patrick MD, MSc; Mercier, Éric MD, MSc; Lamontagne, François MD, MSc; Chassé, Michael MD, PhD; Stelfox, Henry T. MD, PhD; Berthelot, Simon MD, MSc; Gabbe, Belinda PhD; Lecky, Fiona MD, MSc; Yanchar, Natalie MD, MSc; Champion, Howard MD; Kortbeek, John MD; Cameron, Peter MD; Bonaventure, Paule Lessard MD, MSc; Paquet, Jérôme MD; Truchon, Catherine PhD; Turgeon, Alexis F. MD, MSc on behalf of the Canadian Traumatic brain injury Research Consortium

Journal of Trauma and Acute Care Surgery: June 2019 - Volume 86 - Issue 6 - p 983–993
doi: 10.1097/TA.0000000000002246
ORIGINAL ARTICLES
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BACKGROUND Tests and treatments that are not supported by evidence and could expose patients to unnecessary harm, referred to here as low-value clinical practices, consume up to 30% of health care resources. Choosing Wisely and other organizations have published lists of clinical practices to be avoided. However, few apply to injury and most are based uniquely on expert consensus. We aimed to identify low-value clinical practices in acute injury care.

METHODS We conducted a scoping review targeting articles, reviews and guidelines that identified low-value clinical practices specific to injury populations. Thirty-six experts rated clinical practices on a five-point Likert scale from clearly low value to clearly beneficial. Clinical practices reported as low value by at least one level I, II, or III study and considered clearly or potentially low-value by at least 75% of experts were retained as candidates for low-value injury care.

RESULTS Of 50,695 citations, 815 studies were included and led to the identification of 150 clinical practices. Of these, 63 were considered candidates for low-value injury care; 33 in the emergency room, 9 in trauma surgery, 15 in the intensive care unit, and 5 in orthopedics. We also identified 87 “gray zone” practices, which did not meet our criteria for low-value care.

CONCLUSION We identified 63 low-value clinical practices in acute injury care that are supported by empirical evidence and expert opinion. Conditional on future research, they represent potential targets for guidelines, overuse metrics and de-implementation interventions. We also identified 87 “gray zone” practices, which may be interesting targets for value-based decision-making. Our study represents an important step toward the deimplementation of low-value clinical practices in injury care.

LEVEL OF EVIDENCE Systematic Review, Level IV.

From the Department of Social and Preventative Medicine (L.M., K.M.B., I.F.), Population Health and Optimal Health Practices Research Unit, Trauma, Emergency, Critical Care Medicine (L.M., F.Lauzier, P.-A.T., K.M.B., I.M., E.M., S.B., P.L.B., A.F.T.), Centre de Recherche du CHU de Québec, Université Laval (Hôpital de l'Enfant-Jésus), Department of Anesthesiology and Critical Care Medicine (F.Lauzier, A.F.T.), Population Health and Optimal Health Practices Research Unit (P.A.), Transfert des Connaissances et Évaluation des Technologies et Modes d'Intervention en Santé, Centre de Recherche du CHU de Québec, Université Laval (Hôpital St François d'Assise), Université Laval; Department of Medicine (F.Lamontagne), Université de Sherbrooke, Sherbrooke; Department of Medicine (M.C.), Université de Montréal, Montréal, Québec; Departments of Critical Care Medicine (H.T.S.), Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada; School of Public Health and Preventive Medicine (B.G.), Monash University, Melbourne, Australia; Emergency Medicine (F.Lecky), University of Sheffield, Sheffield; Trauma Audit and Research Network, United Kingdom; Department of Surgery (N.Y.), Dalhousie University, Halifax, Nova Scotia; Department of Surgery (H.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland; Department of Surgery (J.K.), University of Calgary, Calgary, Alberta, Canada; The Alfred Hospital (P.C.), Monash University, Melbourne, Australia; Division of Neurosurgery, Department of Surgery (P.L.B., J.P.), Université Laval; Institut National D'Excellence en Santé et en Services Sociaux (C.T.), Québec, Canada.

Address for reprints: Lynne Moore, CHU de Québec Research Center (Enfant-Jésus Hospital), Population Health and Optimal Health Practices Research Unit, Trauma, Emergency, Critical Care Medicine, 1401, 18e rue, local H-012a, Québec, Canada G1J 1Z4; email: lynne.moore@fmed.ulaval.ca.

The results of this study were presented at the 77th Annual Meeting of AAST and Clinical Congress of Acute Care Surgery and 4th World Trauma Congress, September 26th-29th, 2018 in San Diego, California.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.jtrauma.com).

Injuries led to 192,000 deaths, 3 million hospitalizations and 27 million emergency department visits in the USA in 2013 and generated medical and work loss costs of US $671 billion.1 In Canada, injury deaths increased by 23% from 13,000 in 2004 to 16,000 in 2010 while costs increased by 35% and are projected to reach $75 billion CAN by 2035.2 Given the huge burden of injury and evidence of unwarranted variation in injury outcomes across health care providers,3–5 efforts to optimize care has the potential to yield major dividends.

Rapid innovation in imaging and therapeutic techniques has led to an exponential rise in the use of tests and treatments that are not supported by evidence and could expose patients to unnecessary harm,6,7 referred to here as low-value clinical practices.8–15 Low-value clinical practices have been estimated to consume up to 30% of health care resources10,12,14,16 but little is known about this issue in the context of injury care. Low-value clinical practices have multiple negative consequences. From a health care system perspective, they strain health care budgets and decrease the availability of resources. From a patient and caregiver perspective, they expose patients to physical and psychological harm, delay effective treatment, and increase direct and indirect expenses.8–10,12,14 Finally, from a societal perspective, low-value clinical practices threaten the sustainability of affordable, accessible health care. Interventions targeting the de-implementation of low-value clinical practices therefore have the potential to reduce waste and improve patient outcomes.15,17

Physicians report overusing resources for fear of legal actions but also because of lack of guidelines on low-value clinical practices.12–14,18Choosing Wisely has developed lists of commonly used tests or procedures whose necessity should be questioned including top five lists for emergency medicine, radiology, pediatric orthopedics, neurology, and surgery.11 However, few apply to injury care and most are based solely on expert consensus. Previous systematic reviews aiming to identify low-value clinical practices have not been specific to injury but have underlined the importance of targeting diagnostic groups to improve feasibility and subsequent knowledge transfer.15,19–22 We aimed to identify low-value clinical practices in acute, intrahospital injury care.

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METHODS

Our study was conducted in six stages following published guidelines for scoping reviews and comprised a literature review followed by a Web-based survey consultation with clinical experts.23,24 The protocol has been published previously.25 Ethics approval was obtained from the institutional research ethics committee.

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Identify Research Questions and Develop Definitions

First, using an iterative approach, the interdisciplinary and intersectorial project steering committee comprising clinicians, allied health professionals and policy and decision-makers identified the following research question for our review: Which clinical practices are considered low-value in acute injury care? Second, the committee used highly-cited literature on health care overuse7,13,14,17 to establish the following working definition of low-value clinical practices: A test or treatment (i.e., admission, monitoring, diagnostic interventions, therapeutic interventions, consultation) that is used in practice but is ineffective or its harm/cost outweighs its benefits. Third, the committee consulted University of California at Los Angeles (UCLA) / Research and Development (RAND) corporation recommendations to establish the following criteria for identifying candidates for low-value injury care: clinical practices identified as low-value in at least one Level I, II, or III study AND considered to be clearly/potentially low-value by at least 75% of experts and not considered clearly beneficial by any expert.

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Identify Relevant Studies

Eligibility Criteria

We included original research, literature reviews, recommendations and guidelines that identified at least one low-value clinical practice specific to injury populations according to the definition given above.11 We included studies on clinical practices specific to intrahospital acute care (in the emergency department or following hospital admission). We excluded: (i) studies with no clear indication for the low-value practice (e.g., based on physician gestalt); (ii) studies based exclusively on populations with combat injuries, osteoporotic fractures, burns, bites, or foreign bodies; (iii) case reports, animal and cadaver studies; (iv) studies on prehospital or postacute clinical practices.

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Information Sources

We systematically searched MEDLINE, EMBASE, Cochrane CENTRAL, BIOSIS/Web of Science, ClinicalTrials and ISRCTN; Thesis repositories (Thesis portal Canada, EtHOS, DART-Europe E-Theses Portal, the National Library of Australia's Trove and ProQuest Dissertations & Theses Global); Websites of health care quality organizations (Agency for Healthcare Research and Quality, Australasian Association for Quality in Healthcare, Canadian Institutes for Health Information, Choosing Wisely, Lown Institute, National Association for Healthcare Quality, National Institute of Health and Care Excellence, National Quality Forum, and World Health Organization) and injury organizations (American Association for the Surgery of Trauma, American Association of Orthopedic Surgeons, American College of Surgeons, American Trauma Society, Australasian Trauma Society, Brain Trauma Foundation, British Trauma Society, Eastern Association for the Surgery of Trauma, International Association for Trauma Surgery and Intensive Care, International Trauma Anesthesia and Critical Care Society, Orthopedic Trauma Association, The Society of Trauma Nurses, Trauma Association of Canada, Trauma Audit Research Network, Trauma.org, and Western Trauma Association.); and patient advocacy organizations including Safer Healthcare Now!

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Search Strategy

We developed a systematic search strategy with an information specialist.26 The strategy was developed for MEDLINE and EMBASE using keywords covering combinations of search terms under the themes injury and low-value clinical practices (Supplemental Digital Content 3, Table 1, http://links.lww.com/TA/B326). This search strategy was then adapted for the other databases.

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Select Studies

Data Management

Citations were managed using EndNote software (version X7.0.1, New York City: Thomson Reuters, 2011). Duplicates were identified and eliminated using electronic and manual screening. Multiple publications based on the same data set were identified by crosschecking authors, dates and settings. In the case of replication, we identified only one publication for analyses using criteria based on study dates (most recent) and sample size (largest).

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Selection Process

Pairs of reviewers with methodological and content expertise (two of four reviewers, L.M., K.M.B., P.A.T., I.F.) independently evaluated all citations for eligibility. Consecutive samples of 500 citations were independently assessed by each reviewer until high agreement was achieved on study inclusion (three samples for kappa > 0.8). Any further disagreement on study eligibility was resolved by consensus and a fifth reviewer adjudicated when necessary (F.L.).

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Chart Material

A standard electronic data abstraction form and a detailed instruction manual were developed and piloted independently by all reviewers on a representative sample of five publications. Pairs of reviewers (L.M., K.M.B., P.A.T., I.F.) independently extracted information on the study design, setting (country, year, language, funding), study objective, study population, low-value clinical practices, and primary outcomes when appropriate. Any discrepancies between reviewers was resolved by consensus and a fifth reviewer adjudicated when necessary (F.L.).

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Collate, Summarize, and Report on Results

Clinical practices were classified according to the type of practice and the clinical speciality.19 Classifications were conducted independently by two reviewers (K.M.B., P.A.T.) and then checked independently by a third reviewer (L.M.- Lauzier). Any disagreements were adjudicated by a fourth reviewer (F.L.). As is common in scoping reviews, the methodological quality of included studies was not evaluated.27 We summarized the level of evidence for each practice by calculating the number of studies by type using an adaptation of Oxford Center for Evidence-based Medicine classifications28: randomized-controlled trials (RCTs) or systematic review of RCTs (I), prospective cohort studies or systematic review of RCTs and prospective cohort studies (II), retrospective cohort, case-control, cross sectional and case series studies or systematic review of any of the former (III), expert consensus and other (IV).

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Consultation

We recruited four groups of experts for the consultation phase using a snowball technique based on the following criteria: representation of clinical expertise involved in acute intrahospital injury care, actively involved in injury research (knowledge of the evidence base for clinical practices) and geographical diversity.29 Recruitment was independent of scoping review results and authorship status to minimize the influence of intellectual or academic biases. Groups were formed according to clinical specialty: emergency physicians, critical care physicians/neurosurgeons, trauma surgeons and orthopedic/spine surgeons. Each group reviewed clinical practices within their area of expertise. For the main objective, we used two phases of consultation. First, we consulted a subgroup of eight experts (two from each specialty) to regroup overlapping clinical practices, harmonize terminology and develop and test our survey. Second, we administered a web-based survey30 asking experts to rate each clinical practice on a five-point Likert scale from clearly low-value to clearly beneficial (see Supplemental Digital Content 1, Fig. 2, http://links.lww.com/TA/B324). These categories mirror the ‘clearly ineffective, grey zone, and clearly effective’ classifications described in the Lancet Right Care series.14,15

After the consultation phase, we applied the a priori criteria described above to identify candidate low-value clinical practices for injury care, that is, practices reported as low-value in at least one Level I, II, or III study AND considered to be clearly/potentially low-value by at least 75% of experts and not considered clearly beneficial by any expert.

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RESULTS

Of 77,733 citations, 1,593 studies were retained for full text review and 815 were included (Supplemental Digital Content 2, Fig. 1, http://links.lww.com/TA/B325). Data extraction led to the identification of 965 clinical practices (Table 1). Over one half were prospective or retrospective cohort studies, 22% were reviews (one third of these systematic), 5% were based on expert opinion, and less than 5% were RCTs. The majority of studies aimed to evaluate the effectiveness of the clinical practice (55%), whereas one quarter aimed to develop guidelines or derive/validate a clinical decision rule. Seventeen percent aimed to evaluate the prevalence of overuse or the efficacy of a de-implementation intervention. Less than 1% aimed to derive or validate quality indicators. More than one third of low-value practices pertained to the treatment of head injury, and most were specific to adult (37%) or pediatric (12%) populations. One half of clinical practices targeted diagnostic interventions, 40% targeted therapeutic interventions and 5% targeted ICU or hospital admission.

TABLE 1

TABLE 1

We approached 39 experts of whom 36 (92%) agreed to participate and completed the survey including 8 of 9 emergency physicians, 9 of 9 critical care physicians, 1 of 1 neurosurgeon, 10 of 12 trauma surgeons, and 8 of 8 orthopedic/spine surgeons from Canada, United States, Australia and the United Kingdom. After the first consultation phase, we identified 150 clinical practices (Tables 2–5 and Supplemental Digital Content 4, Table 2, http://links.lww.com/TA/B327). In the Web-based survey, 66 clinical practices were considered clearly or potentially low-value by at least 75% of respondents. Thereafter, we identified 63 clinical practices that met our criteria as candidates for low-value injury care, that is, they were reported as low value in at least one Level I, II, or III study, considered clearly or potentially low value by at least 75% of respondents and not considered clearly beneficial by any of the experts (Tables 2–5). Among these clinical practices, 13 were supported by do-not-do recommendations in internationally recognized clinical practice guidelines (i.e., indications were the same or very similar). Nine practices included as do-not-do recommendations in clinical guidelines were not selected by our criteria (Supplemental Digital Content 4, Table 2, http://links.lww.com/TA/B327).

TABLE 2

TABLE 2

TABLE 3

TABLE 3

TABLE 4

TABLE 4

TABLE 5

TABLE 5

We identified 33 candidates for low-value injury care in the emergency room of which five were related to hospital admission for abdominal trauma or mild traumatic brain injury (TBI) and 20 were related to imaging including computed tomography (CT) or X-ray for mild TBI, ankle, knee, chest and cervical spine injuries (Table 2). We also identified 15 ED practices in the gray zone including repeat head CT in adult mild complicated TBI and hospital admission in pediatric isolated skull fracture (Supplemental Digital Content 4, Table 2, http://links.lww.com/TA/B327). Nine low-value practices were selected for general trauma surgery, six of which were related to operative management of liver, renal, splenic, and neck injuries (Table 3). In addition, we identified 15 practices in the gray zone including follow-up imaging for nonoperative blunt renal injury and surgical management of high-grade pancreatic or renal injuries (Supplemental Digital Content 4, Table 2, http://links.lww.com/TA/B327). We identified 15 low-value practices in the intensive care unit of which eight targeted TBI (Table 4). Four were related to medications (corticosteroids, antibiotics and antiseizure prophylaxis) and four were related to fluids and blood products (albumin, colloids, platelet and red blood cell transfusion). Twenty-six (63%) of ICU clinical practices were in the gray zone (Supplemental Digital Content 4, Table 2, http://links.lww.com/TA/B327) including neurosurgical consultation in acute mild complicated TBI, decompressive craniotomy and hourly neurological assessments >24 hours for stable TBI. Five low-value practices were identified in orthopedics targeting follow-up consultation, spine service consultation, repeat X-ray, orthosis for thoracolumbar burst fractures and preoperative blood tests (Table 5). Thirty-one (86%) orthopedic practices in acute injury care were classed in the gray zone of which six targeted follow-up consultation, nine imaging, and five immobilization (Supplemental Digital Content 4, Table 2, http://links.lww.com/TA/B327).

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DISCUSSION

We identified 63 clinical practices that met criteria for low-value intrahospital injury care. These potential low-value practices are supported by empirical evidence and expert opinion. Conditional on the results of future research, they represent potential targets for guidelines, overuse metrics and de-implementation interventions. We also identified 87 clinical practices in the gray zone, which are not consistently supported by empirical studies and expert opinion. While these practices require more evidence before being labeled low-value, they may be interesting targets for value-based decision-making.

The literature on low-value clinical practices in injury care is scarce. Internationally recognized medical associations publish guidelines on injury care.31–34 However, few pertain to clinical practices that should be avoided. Health care quality organizations including Choosing Wisely and the National Institute for Health and Care Excellence publish recommendations specific to low-value practices but few target injury care.35,36 In addition, these recommendations are often based only on expert consensus.20 Three previous literature reviews on low-value care across a range of diagnostic groups identified nine low-value practices specific to injury care.14,19,20,37 We were able to identify many more practices because targeting a specific diagnostic group allows for a much more sensitive review strategy.15 With over 50,000 citations to screen and more than 1,400 documents to extract in our study, a similar search strategy with no restrictions on diagnosis would have been unfeasible.

Twenty-six percent of low-value practices identified in our review were related to imaging. This is consistent with a previous review of low-value care measures20 and may be because the value of imaging is relatively easy to evaluate retrospectively. Unnecessary imaging generates important costs14,38 and may expose patients to high doses of radiation with non-negligible long-term risks of cancer.39–41 We retained 12 low-value practices on imaging which are already supported by guidelines and/or widely used clinical decision rules and eight additional clinical practices which are potential targets for low-value imaging. We identified 21 low-value practices related to operative (versus nonoperative) management of which two are included in EAST guidelines.31 A recent review found 71 low-value practices in general surgery representing an estimated annual cost of 153 million euros per year in the United Kingdom.42 However, none of these practices pertained to injury. Seventeen practices identified in our review pertained to medications of which five were supported by do-not-do recommendations in clinical guidelines.31,33,35,36 There is a large body of literature on overprescribing in primary care.14,43–45 However, an important knowledge gap on in-hospital medication exists, probably in part due to the fact that hospital prescriptions are not recorded in administrative databases. Other low-value practices identified in our review were hospital and ICU admission (n = 11) and follow-up consultation (n = 7). Literature on overuse in these areas is sparse, possibly because they are very context-specific. Nine practices included in internationally recognized guidelines as practices to avoid were not retained in our study, all because less than 75% of experts identified them as clearly or potentially low-value. This discordance could be due to our strict selection criteria based on literature evidence and agreement of more than 75% of experts. Guidelines are often based on few, low-quality studies or expert consensus, but rarely both.46 It may also be explained by differing influences of local context, industry pressure or single highly-mediatized studies.13,15,21,47,48 It does suggest that moving forward, guidelines/metrics on low-value injury care should be based both on evidence from high-quality experimental or observational studies AND expert opinion and should account for the possible influence of local context. Also, the consensus process should strive to minimize intellectual, academic and financial biases.

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Strengths and Limitations

This study represents a rigorous, exhaustive review of the literature on low-value clinical practices in injury care. Results from our scoping review are supported by a consultation study with 36 experts representing the clinical specialties involved in trauma care on three continents. The participation rate of over 90% demonstrates the high level of knowledge-user interest in this topic. In addition, experts are all involved in clinical research in acute injury care so are likely to have good knowledge of the evidence-base on clinical practices for injury admissions.

This study does have limitations that should be considered in the interpretation of results. First, for feasibility reasons, our search strategy was based on key words related to low-value care and was therefore dependent on authors' judgment of the value of clinical practices. This may have led us to miss some low-value practices. For example, authors of the Randomized Evaluation of Surgery with Craniectomy of Uncontrollable Elevation of Intracranial Pressure (RESCUEicp) trial that observed lower mortality but worse functional outcomes in the intervention group did not clearly identify decompressive craniectomy as a low-value practice.49 However, by thoroughly screening article references, gray literature including injury organizations and health care quality websites, and consulting experts for further references, we are confident that we captured a large proportion of potentially low-value clinical practices that have been reported in the literature. Second, for feasibility reasons, we restricted the review to studies published since 2006. We may therefore have missed some important RCTs published earlier, for example, the National Acute Spinal Cord Injury Studies I on high-dose steroids for spinal cord injury50 and the Harborview trial on antiseizure prophylaxis in traumatic brain injury.51 However, both these practices were captured through review of guidelines. Fourth, due to the scoping design of our review, we did not evaluate methodological quality. Strength of evidence was only based on study design. Fifth, the last phase of the review was based on a single web survey therefore represents the results of a consultation rather than expert consensus. In addition, we used a convenience sample and only one neurosurgeon was surveyed. Finally, to identify targets for de-implementation we will need data on frequency (how frequently is the clinical practice actually used?), inter-provider variations (is there evidence of practice variation?) and economic impact (would deadoption lead to important savings?).52,53 These aspects will be incorporated into the following subsequent phases of the Canadian Program for Monitoring Overuse in Injury Care; a systematic review to GRADE evidence for low-value clinical practices identified in this review,54 a RAND-UCLA expert consensus study to develop a set of quality indicators targeting low-value practices, a multicenter retrospective cohort study to derive and validate metrics for the quality indicators and a cluster RCT to evaluate the effectiveness of quality indicators in an audit-feedback intervention. The research program will also allow us to take into account the specificities of low-frequency, high-risk injuries.

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CONCLUSION

This study fills a major knowledge gap on medical procedure overuse in acute injury care. Results will inform research priorities and the development of metrics to measure overuse. This knowledge will provide a solid basis for the development of interventions targeting deimplementation, such as clinical decision rules and shared decision making tools. This has the potential to decrease costs, increase resource availability, and reduce mortality and morbidity due to unnecessary tests and treatments and reduce patient stress and physicians' workload.

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AUTHORSHIP

L.M. led the conception and design of the study, acquisition of data, analysis and interpretation of data, and drafted the article. F.Lauzier made substantial contributions to the conception and design, the acquisition of the data, the analysis and the interpretation of data. He revised the article critically for important intellectual content and gave final approval of the version to be published. P.-A.T. made substantial contributions to the acquisition of the data, the analysis and the interpretation of data. He participated in drafting the article and gave final approval of the version to be published. K.M.B. made substantial contributions to the acquisition of the data. She revised the article critically for important intellectual content and gave final approval of the version to be published. I.made substantial contributions to the acquisition of the data. She revised the article critically for important intellectual content and gave final approval of the version to be published. P.A. made substantial contributions to the conception and design, the acquisition of the data, the analysis and the interpretation of data. He revised the article critically for important intellectual content and gave final approval of the version to be published. É.M. made substantial contributions to the conception and design and the acquisition of the data. He revised the article critically for important intellectual content and gave final approval of the version to be published. F.Lamontagne made substantial contributions to the acquisition of the data. He revised the article critically for important intellectual content and gave final approval of the version to be published. M.C. made substantial contributions to the acquisition of the data. He revised the article critically for important intellectual content and gave final approval of the version to be published. H.T.S. made substantial contributions to the conception and design and the acquisition of the data. He revised the article critically for important intellectual content and gave final approval of the version to be published. S.B. made substantial contributions to the conception and design and the acquisition of the data. He revised the article critically for important intellectual content and gave final approval of the version to be published. B.G. made substantial contributions to conception and design. She revised the article critically for important intellectual content and gave final approval of the version to be published. F.L. made substantial contributions to the acquisition of the data. She revised the article critically for important intellectual content and gave final approval of the version to be published. N.Y. made substantial contributions to the acquisition of the data. He revised the article critically for important intellectual content and gave final approval of the version to be published. H.C. made substantial contributions to the acquisition of the data. He revised the article critically for important intellectual content and gave final approval of the version to be published. J.K. made substantial contributions to the acquisition of the data. He revised the article critically for important intellectual content and gave final approval of the version to be published. P.C. made substantial contributions to the acquisition of the data. He revised the article critically for important intellectual content and gave final approval of the version to be published. P.L.B. made substantial contributions to the acquisition of the data and the analysis and the interpretation of data. She revised the article critically for important intellectual content and gave final approval of the version to be published. J.P. made substantial contributions to the acquisition of the data and the analysis and the interpretation of data. He revised the article critically for important intellectual content and gave final approval of the version to be published. C.T. made substantial contributions to the acquisition of the data. She revised the article critically for important intellectual content and gave final approval of the version to be published. A.F.T. made substantial contributions to the conception and design, the acquisition of the data, the analysis and the interpretation of data. He revised the article critically for important intellectual content and gave final approval of the version to be published.

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DISCLOSURE

Conflict of interest and source of funding: This research is funded by the Canadian Institutes of Health Research (Foundation grant, 353374) and the Fonds de Recherche du Québec – Santé (career award, L.M., F.Lau, F.Lam, M.C.). Patrick Archambault is supported by a Clinical-Embedded Scientist Award from the CIHR. Dr Turgeon is the Canada Research Chair in Critical Care Neurology and Trauma. For the remaining authors, no conflicts were declared.

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Keywords:

Low-value care; trauma systems; scoping review; expert survey

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